May 2nd, 2013 by HKS Research Team
Healthcare reform has driven and intensified the challenge of transforming our healthcare delivery system to reduce costs and improve patient care, as mandated by legislation such as the Affordable Care Act and the 2010 Patient Protection Act. These transformations place new demands on hospitals to improve the quality and safety of patient care delivery while containing costs, requiring hospitals to provide more efficient care. In addition to changing how hospitals operate, these demands will change how healthcare facilities are designed and built.
Lean principles, originally developed for manufacturing, are being applied to the operation and design of healthcare facilities with the goals of eliminating waste, reducing patient wait time, improving patient safety, and lowering healthcare costs. There are many differences between the traditional design process and one that incorporates Lean operations improvement activities in the design process, including philosophy, perspective, design milestones, amount of time spent in each phase and the people involved in the design.
|Traditional Design Process
||Lean Driven Design Process
||Focus on processes that add value for the patient, staff and family members
|Starts with programming
||Starts with observation of operational processes
|User groups are made up of staff leaders within a department or service
||Value-stream focused teams include key stakeholders who are involved across the whole process of delivering the service to the patient are used to analyze the process
|Each user group provides feedback to designers about their departments or services
||Multidisciplinary consensus based, future-state processes drive the development of the floor plan
|Floor plan diagrams are adjusted to accommodate existing operations and processes
||Floor plan diagrams are used to validate the value stream, optimize future improvements
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April 22nd, 2013 by Roy Gunsolus
Hospitals are huge energy consumers. Only fast-food restaurants use more energy. Saving $1 in energy equals $20 in new revenue (American Hospital Association 2009 based on 5 percent margin for U.S. hospitals). If efficiently designed, a facility can reap a 30 to 50 percent reduction in annual energy costs, which equates to significant added revenue.
Building Orientation and Passive Strategies Building orientation and passive strategies should be optimized before mechanical and active strategies are considered. Gunsolus suggests looking at the following building orientation and passive strategies:
- Respond to solar exposure
- Harvest the natural breezes
- Maximize natural daylight
- Select high-efficiency glass
- Consider exterior shading devices
Benefits of a Healthy Work Environment The largest healthcare expense for providers is staff salaries, benefits and insurance. Designing a sustainable facility that provides views to nature and introduces natural light may have intangible benefits that far exceed energy savings since they are a much larger piece of the financial pie. Gunsolus pointed out that a healthier workplace environment offers:
- Increases in employee productivity
- Decreases in nursing turnover rates by 7 percent (according to a Michigan State University Study, Bronson Methodist Hospital, Michigan)
- Decreases in employee tuberculin conversion rates (According to Annals of Internal Medicine, November 2000)
- Reduction in employee absenteeism
In addition, a healthier hospital environment provides:
- Recruiting advantages
- Better treatment outcomes
- Risk mitigation
- Improved public perception
- Reduced medical errors
Healthy Building Product Tips One of the most important developments in the last 10 to 15 years is a focus on identifying and using healthy building materials. Nowhere is this more important than the healthcare environment. To maximize a healthy building, Gunsolus suggests:
- Avoiding potentially harmful chemicals even if the extent of the potential damage is not certain
- Promoting product transparency by encouraging product suppliers to fully disclose the chemicals in their products. Health Product Declarations (HPDs), is a way of standardizing how chemical content is reported and is included in the forthcoming LEED v4.
Hospital success in the future will likely be tied to better Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and Press Ganey scores, which define patient satisfaction and quality of care. Architects and engineers can certainly affect these criteria through design.
Heapy Engineering and Wright State University co-hosted the educational and networking event for healthcare providers and industry partners. The symposium began with a keynote luncheon followed by two panel discussions on sustainably based healthcare delivery, operations and management.
April 17th, 2013 by Craig Beale
The demands on health care facilities are always changing, but as health care institutions prepare themselves for the coming years, they will face tremendous challenges. In the health care reform era, health care systems will have to be more efficient, doing more with less, while at the same time they are caring for more patients. As a result, we will see several trends.
- Fewer big projects, more incremental growth. In the last two decades, we’ve seen many new campuses and greenfield projects. With future cost constraints, health care systems will be more risk averse and return to the facility master plan. They’ll employ building strategies that are incremental and seek to maximize their campuses with small and medium scale projects.
- Outpatient care facilities will move center stage. As providers are incented to deliver care efficiently in ambulatory settings, ancillary care facilities that were part of a huge campus will move up the priority list and away from the hospital. Health care systems will devote more resources to create a true distribution of providers, with medical office buildings, hospitals without beds, and outpatient clinics in venues more accessible to patients. This may mean satellite facilities will be woven into heavily trafficked urban settings, suburban retail malls, or that they will stand alone in rural towns. The good news for facility planners is that these new locations often have lower land costs and can afford architects a more creative configuration than when trying to squeeze a facility into an existing footprint.
- Existing hospitals will need to be retooled. As outpatients move away from acute care settings, inpatient facilities will find themselves treating very ill patients. The current hospital configuration, with many private rooms for medical/surgical patients, may not lend itself to optimal care for more critical patients. In many ways, our hospitals are dinosaurs. I foresee a series of renovations or expansions as health care systems make these facilities able to accommodate the coming population. Hospitals may need to add telemetry units, more ICU beds, or upgrade the facility infrastructure to encompass information technologies necessary for clinicians to care for these patients efficiently.
- In the near term, emergency departments will proliferate. At HKS, we are working on a number of ED projects, including free-standing facilities. Health care systems have taken a lesson from the experience in Massachusetts: after health coverage expanded, ED visits spiked. When patients don’t have a historical relationship with a doctor or clinician, they tend to present in the ED. These new or expanded facilities will accommodate the newly insured patients.
How best to respond to these trends? Flexibility. I have long been an advocate of avoiding over customization. Health care systems operations drive facility design, but facility planners also must take into account how these operations will change over time. They will need to seek out building designs that can accommodate evolutions in physical plant systems and information technologies.
Even with the uncertainties implicit in the current health care reform implementation, we have some clients forging ahead with major building projects. These clients are certainly watching the demographic shift—with numbers of elderly growing nationwide—that will demand more health care facilities. We know our current health care delivery model is unsustainable, and this creates a challenge for facility planners. To keep pace, facilities now on the drawing board will have to be more efficient and technologically advanced than any others in history. These are challenging times, but also exciting times.
April 4th, 2013 by HKS Research Team
The United States is in the midst of a healthcare upheaval – from governmental channels as well as a care culture shift and higher client demands. Through all of this, the trend towards all-private inpatient rooms has been spurred on, even being codified into the Facility Guidelines Institute’s Guidelines for Design and Construction of Health Care Facilities: “The maximum number of beds per room shall be one unless the functional program demonstrates the necessity of a two-bed arrangement. Approval of a two-bed arrangement shall be obtained from the licensing authority”.
In the Health Environments Research & Design Journal, authors Stephen Verderber, ArchD, RA, NCARB and Lindsay G. Todd, MArch and HKS Healthcare Fellow 2010 take a second look at the semi-private inpatient room as a viable model for US healthcare. They explore the following points:
- The private-room “standard” and drivers for the shift
- The semi-private room model in international settings
- Proposed semiprivatism model for select cohorts
Read the rest of this entry »
February 27th, 2013 by HKS Research Team
Healthcare delivery systems are becoming increasingly complex as care delivery integrates and yields multidisciplinary teams. The increased complexity places a higher emphasis on communication and collaboration. Research indicates that an environment in which teamwork thrives leads to greater job satisfaction for caregivers, more responsive and patient sensitive service and the delivery of more clinically effective and cost effective healthcare. The need for effective communication and collaboration could be considered in conflict with trends to decentralize nursing in order for nurses to spend more time with patients and to increase their visibility into patient rooms.
Most modern unit layouts fall into one of three categories.
- Centralized nurse station. In this model a full nurse station is placed in a central location and used by all caregivers in a patient unit. This model originated as a place to keep physical charts and patient information.
- Decentralized nurse station. This model has been driven by the desire to bring the care providers closer to patients and their families. It is loosely described as any arrangement of multiple nursing stations throughout a unit.
- Hybrid. This third model has evolved from the first two. A typical hybrid model includes a large centralized station with multiple touchdown areas throughout the unit.
A study, published in the Fall 2012 HERD Journal, by Ying Hua at Cornell University has evaluated a fourth category of unit design. The researchers refer to this design as a “multi-hub”. The study took place at Meridian Health’s Jersey Shore University Medical Center (JSUMC) in Neptune, New Jersey. JSUMC completed an addition which included the relocation of three medical/surgical units. All three of the new units implemented the multi-hub design, where each unit contains three nursing neighborhoods. Each neighborhood contains a central nursing station with oversight of 12 patient rooms for a total of 36 rooms on the unit. The project’s designers hoped that the neighborhood concept would increase communication and teamwork, while also minimizing walking distances for nurses throughout each shift.
A pre/post research design was employed to examine the impact of the new design on the staff and patient satisfaction. Four nursing units were selected for the study. Results of the study were informative. Read the rest of this entry »
February 21st, 2013 by Ashley Dias
Several weeks ago I had the unique opportunity to tour the entire continuum of care in a single day. It was the kick-off tour for a strategic master plan HKS was awarded in New England. In an effort to get a lay of the land before diving deep into the volumes, demographics, and architectural plans we did a fly-by of all facilities in the system. The contrasts of purpose in the continuum and what we value in healthcare became really apparent when looking at each piece of the continuum with context from the others. In our tour we saw acute care hospitals, freestanding clinics, ambulatory care centers, skilled nursing facilities, assisted living environments, and psychiatric hospitals. It was a profound experience to see the healing going on in the system and across the continuum, essentially all at once. To me it underscored three important thoughts:
- One, every portion of the continuum of care is important and necessary, and should be respected. Sometimes the most critical healing is occurring outside the walls of the hospital-proper.
- Two, ambulatory care is both the heart and limbs of the continuum. Clinics provide care across all service lines and to all ages. Ambulatory care is the front line of healthcare. Everyone pulses through it and it reaches out into the community, literally, by design of the network.
- Three, it’s extremely important when preparing a strategic master plan to consider a system’s entire care network. They each feed and inform one another, and will only continue to be more connected as policy takes effect. You often see diagrams of system’s networks as connected dots. I think it’s more appropriate to visualize and think of networks as a bicycle wheel; one wheel connected by many spokes.
It’s easy to become hyper-focused on one spoke of the wheel, as we design and consult with our clients on projects. However, when we have the opportunity to use a wider-lens, we should. Your thoughts?
February 20th, 2013 by Rachel Saucier
Cost reduction, waste elimination and collaboration are center stage in every hospital today. The integrated, lean project delivery method addresses these issues and benefits hospitals with robust end-user involvement throughout the design process.
For the past year, architects, builders and Akron Children’s Hospital’s Lean Six Sigma process improvement team have been planning a new $200 million patient tower in Ohio. Using lean and evidence-based design principles, department teams at Akron, in conjunction with the architects, designed the new emergency department using small scale models, including paper doll cutouts, cups and yarn to identify types of rooms. Using a hands-on end user approach, the staff designed their ED using paper cutouts of individual rooms. Key adjacencies and the numbers and types of rooms were identified by the staff. Using block plans of each floor separated by plastic cups, colored yarn representing the seven flows of healthcare was used to note key inter- and intra-departmental adjacencies.
Architectural plans were tested in full-scale mock-ups constructed in a local warehouse. This allowed doctors, nurses and patients to walk down hallways, enter exam rooms and reach for supplies – catching potential problems well before the real construction begins.
Tips to Design Lean:
- Involve individuals from the value stream – each step involved in the process of delivering a service to the customer.
- Be prepared, but nimble with planning.
- Robust end user preparation is imperative to obtain the optimal outcomes. Read the rest of this entry »
January 9th, 2013 by HKS Research Team
Hospitals are always looking for savings opportunities and ways to improve financial. Inpatient falls are costly to both the patient and the hospital; falls and injuries account for approximately 12.5% of total hospital professional liability (HPL) claim costs, which equates to approximately $396 per hospital bed in 2010, and HPL costs are on the rise. “Hospital-acquired injuries from falls in patient rooms are covered on the list of Never Events published by the Centers for Medicare and Medicaid Services (CMS),” (Calkins 2012). These Never Events are a serious matter, because hospitals are denied complete reimbursement for such events since CMS has deemed them preventable, among other reasons.
A study was recently published by Ideas Institute through The Center for Health Design, which solely examines the impact of design characteristics on patient falls and does not take intrinsic factors such as poor balance into account. The following are findings from data collected from 12 hospitals, based on a total of 995 falls in 670 patient rooms from the previous year; conclusions address the bathroom, flooring, general environment, and patient room layout.
Findings: Read the rest of this entry »
January 9th, 2013 by Rachel Saucier
It doesn’t pay to incorporate a broken process into a new building, so say administrators at Children’s Medical Center Dallas and Children’s of Alabama. When designing their new facilities, they set out to do things diﬀerently.
These two hospitals had in-depth expansion project experience, but neither considered innovation during the process of facility design. Faced with pressure to produce outcomes in operational performance, patient satisfaction and physician approval that exceeded anything produced in the past, the systems knew they had to look at this challenge through a new lens.
Both systems engaged in breakthrough lean visioning and operational innovation sessions that mapped each functional activity (clinical, ancillary, support) and identified ways to radically improve the service that they were providing and change the way business is done. Every process was mapped and new leaders emerged with the redesigned processes. In the end, both the process and the product were noticeably different.
The Do’s and Don’ts of Lean Facility Planning
- Listen to the voice of the customer.
- Engage the patients and families as much as possible.
- Learn from your current state – the good and the bad.
- Bring in a fresh set of eyes.
- Go to the gemba – the place where the work is being done.
- Give the staff ownership. When it becomes “their” process they will become the front line ambassadors for change.
- Work backward from a target goal so every meeting is purposeful and occurs at the right time.
- Sweat the small stuff.
- It’s natural to spend lots of time on the big messy issues you are trying to solve, but some of the “minor details” can make a huge impact on day-to-day work at the bedside. Examples: diaper scale shelf in bathroom, deeper isolation supply cabinets, theft-proof gaming systems and task light for drawing labs.
- Embrace the use of mock-ups and encourage rapid prototyping.
- Require full participation from all stakeholders, and adopt an “equal voice” rule in meetings.
- Consider program development and operations concurrently with design and construction.
- Implement a comprehensive review of organizational workflow and downstream effects.
- Solicit more frontline staff input from onset of design through completion.
- Appreciate the complexity and importance of equipment planning.
- Use standardization as a primary guiding principle.
- Synchronize the approach of the technology and construction implementation schedule.
- Improve physician engagement.
- Establish leaders for each floor/area.
- Schedule and conduct meetings to meet their schedules.
- Provide updates that are pertinent to what they want to hear.
- Keep most decisions at project team level.
- Escalate unresolved issues to Executive Steering Committee.
- Underestimate the logistics of managing and facilitating large groups of people during this process.
- Get started too late – if you have the right team in place, operations should inform design, not vice-versa.
- Forget the power and importance of visioning – from your customer, your staff, administration, and your design and construction team.
- Deviate from principles of standardization.
- View the project as “facility-centric.”
- Avoid or postpone crucial conversations with staff and medical staff (transparency dispels many unrealistic expectations).
- Implement Electronic Medical Records and construction and occupancy of facility within close timeframes.
- Deviate from team/project goals.
- Conduct team sessions longer than two hours – if you do, provide food.
- Change direction after the final decision is made.
- Allow scope creep.
January 2nd, 2013 by Doug Compton
Natural light is one of the primary design drivers for the Benjamin Russell Hospital for Children. The ability to bring in natural light and have views to the outside is important for the well-being of patients, staff, and families. Great effort went into making sure the public spaces and passageways had natural light and views and therefore were located on the perimeter of the hospital. This helps significantly with way-finding by not traversing the through corridors buried in the bowels of the hospital. The emergency department entrance was located along the same street as the main entry to minimize confusion when a parent brings a child during an emergency.
The emergency waiting is connected to the lobby by a glassed passage way along the perimeter. Family areas and rest areas on the patient floors have views outside. Large windows in the family zones of the patient rooms provide great views of downtown Birmingham and Red Mountain, an area landmark. There are even clerestory windows in the patient room toilets to bring in natural light.
Another important goal for the Benjamin Russell Hospital for Children was sustainability – to be a good neighbor to the community and the environment. The major facades of the building are oriented north and south to minimize undue solar gain and heat. An added benefit is the best views from all the patient rooms are to the north (downtown Birmingham) and to the south (Red Mountain). The glass curtainwall is composed of energy efficient insulated low-e glass. Roof areas of the podium are planted with vegetation to help minimize storm water runoff and add insulation. Plus, the roofs become pleasant
green spaces to view from the patient rooms above. As a result and along with several other sustainable features, the Benjamin Russell Hospital for Children has achieved a silver LEED rating.